Costs of Covering, Treating Patients With HIV

Gary Owens, MD, president of Gary Owens Associates, discusses the financial burdens of HIV and the challenges payers face when covering this patient population.

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Welcome back to PopHealth Perspectives, a conversation with the Population Health Learning Network where we combine expert commentary and exclusive insight into key issues in population health management and more.

Today we are joined by Dr. Gary Owens, president of Gary Owens associates. He discusses the financial burdens of HIV and the challenges payers face when covering this patient population. Gary?

Thanks Sam. I'm Gary Owens. I am a former payer, medical director, and prior to that, a former primary care physician. For a decade or so, I’ve been in the consulting world and head of my own consulting organization. So it's a pleasure to chat with you this afternoon.

So can you comment on the financial burdens of HIV?

I sure can. And let's take a look at the financial burden from a, maybe a system perspective. I think that being a former payer makes the most sense, at least according to the most recent CDC data that there are about 1.2 million people in the US who are living with HIV, mostly as a chronic disease.

We are fortunate that the number of new HIV infections has really been plateaued for a number of years now with just a nudge under 40,000. But there's still a substantial cost associated with this disease state.

The annual cost of HIV care in the antiretroviral treatment era is estimated again, according to the CDC, to be somewhere around $23,000-$30,000 a year. And there was even a CDC publication of a lifetime estimate of HIV cost in somewhere around $380,000 for a lifetime of care. So it's a very costly per patient treatment.

The majority of the cost is for the antiretroviral medications, about 60% of all of that cost, another 15% or 20% is for other chronic disease medications, opportunistic infection, treatments, and prophylaxis of other disease states.

And then whatever's left over is non medication and these patients compared to patients without HIV. There was a study published in PharmacoEconomics back in 2020 that that showed that these people are about 7 times more costly on an annual basis than match cohorts with the same age and comorbidity.

So it's a way of saying systemically it's a very significant disease state. One payers do pay attention to.

So what are some challenges to covering patients with HIV? If you want to talk about anything regarding prior authorization, reimbursement practices.

The challenges of covering patients with HIV have not been large for payers except for the cost. And then of course, that cost gets reflected in the premium cost, as well as direct cost to our self-funded employers. Most of the HIV medications still are on formularies.

There's only a handful typically where there's a significant overlap in categories where maybe a payer will have a preferred agent, but because there are so many different mechanisms of action out there. And then again, so many drugs that are out there for people who develop resistance and have later stage disease.

I think we as payers cover most of them, the agents, because they are so expensive are prior authorized. So that does create a burden on both the payer to have to do the PAs as well as the prescribers who are usually infectious disease or even primary care doctors who live in areas of high disease prevalence.It creates a burden there.

As I pointed out the overall prevalence of HIV in the last decade or so, it's been pretty stable. Just around that 1.2-1.4 million people. You can add to that though what we think is about 10% more who are undiagnosed and don't know it. So maybe 150,000 or 160,000.

And therein lies a problem because number 1, their disease is advancing and likely to create some more costly scenarios when it's diagnosed. And second, they could be actually transmitting the disease, unaware of their ability to transmit it. And that leads us to those comments on PrEP, right?

Again, some data from the CDC and the AIDS vaccine advocacy coalition show that between 2016 and 2020, that 4-year period, there were only about 200,000 initiated preexposure prophylaxis prescriptions, contrast that with a million and a half plus people living with AIDS every year. And that's a relatively small number, really not probably where it should be. And there are I think a number of reasons for that.

Number 1 is a lot of unawareness by patients that PrEP is available. I think there's unawareness by people who may be at risk of contracting HIV. There's a lot of focus on men who have sex with men and IV drug users, but we certainly also know that you don't have to be in those groups to be at risk you know, being sexually active can also constitute a risk as well.

And so I think there's a significant amount of underutilization. I don't think at this point, payers are actively promoting PrEP and I don't even know whether it's the payer responsibility to do that.

Yes, it's a public health issue and yes we can do more at the public health level to promote it. And I think payers maybe want to join in on that and work hand in hand with public health to do that because ultimately preventing HIV is a way to prevent not only the morbidity and the human suffering, but also to prevent downstream cost.

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